{{ header }}
<div class="site-breadcrumb">
  <div class="container">
    <ul class="breadcrumb">
      {% for breadcrumb in breadcrumbs %}
      <li><a href="{{ breadcrumb.href }}">{{ breadcrumb.text }}</a></li>
      {% endfor %}
    </ul>
  </div>
</div>
<div class="page-main user-center">
  <div class="container">
    <div class="row">
      {{ column_left }}
      {% if column_left and column_right %}
      {% set class = 'col-sm-6' %}
      {% elseif column_left or column_right %}
      {% set class = 'col-sm-9' %}
      {% else %}
      {% set class = 'col-sm-12' %}
      {% endif %}
      <div id="content" class="{{ class }}">
        {{ content_top }}
        <h1 class="heading">{{ heading_title }}</h1>
        <p>{{ text_description }}</p>
        <form action="{{ action }}" method="post" enctype="multipart/form-data" class="form-horizontal">
          <div class="form-group required">
            <label class="col-sm-2 control-label" for="input-to-name">{{ entry_to_name }}</label>
            <div class="col-sm-10">
              <input type="text" name="to_name" value="{{ to_name }}" id="input-to-name" class="form-control" />
              {% if error_to_name %}
              <div class="text-danger">{{ error_to_name }}</div>
              {% endif %}
            </div>
          </div>
          <div class="form-group required">
            <label class="col-sm-2 control-label" for="input-to-email">{{ entry_to_email }}</label>
            <div class="col-sm-10">
              <input type="text" name="to_email" value="{{ to_email }}" id="input-to-email" class="form-control" />
              {% if error_to_email %}
              <div class="text-danger">{{ error_to_email }}</div>
              {% endif %}
            </div>
          </div>
          <div class="form-group required">
            <label class="col-sm-2 control-label" for="input-from-name">{{ entry_from_name }}</label>
            <div class="col-sm-10">
              <input type="text" name="from_name" value="{{ from_name }}" id="input-from-name" class="form-control" />
              {% if error_from_name %}
              <div class="text-danger">{{ error_from_name }}</div>
              {% endif %}
            </div>
          </div>
          <div class="form-group required">
            <label class="col-sm-2 control-label" for="input-from-email">{{ entry_from_email }}</label>
            <div class="col-sm-10">
              <input type="text" name="from_email" value="{{ from_email }}" id="input-from-email" class="form-control" />
              {% if error_from_email %}
              <div class="text-danger">{{ error_from_email }}</div>
              {% endif %}
            </div>
          </div>
          <div class="form-group required">
            <label class="col-sm-2 control-label">{{ entry_theme }}</label>
            <div class="col-sm-10">
             {% for voucher_theme in voucher_themes %}
              {% if voucher_theme.voucher_theme_id == voucher_theme_id %}
              <div class="radio">
                <label>
                  <input type="radio" name="voucher_theme_id" value="{{ voucher_theme.voucher_theme_id }}" checked="checked" />
                  {{ voucher_theme.name }}</label>
              </div>
              {% else %}
              <div class="radio">
                <label>
                  <input type="radio" name="voucher_theme_id" value="{{ voucher_theme.voucher_theme_id }}" />
                  {{ voucher_theme.name }}</label>
              </div>
              {% endif %}
              {% endfor %}
              {% if error_theme %}
              <div class="text-danger">{{ error_theme }}</div>
              {% endif %}
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label" for="input-message"><span data-toggle="tooltip" title="{{ help_message }}">{{ entry_message }}</span></label>
            <div class="col-sm-10">
              <textarea name="message" cols="40" rows="5" id="input-message" class="form-control">{{ message }}</textarea>
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label" for="input-amount"><span data-toggle="tooltip" title="{{ help_amount }}">{{ entry_amount }}</span></label>
            <div class="col-sm-10">
              <input type="text" name="amount" value="{{ amount }}" id="input-amount" class="form-control" size="5" />
              {% if error_amount %}
              <div class="text-danger">{{ error_amount }}</div>
              {% endif %}
            </div>
          </div>
          <div class="buttons clearfix">
            <div class="pull-right"> {{ text_agree }}
              {% if agree %}
              <input type="checkbox" name="agree" value="1" checked="checked" />
              {% else %}
              <input type="checkbox" name="agree" value="1" />
              {% endif %}
              &nbsp;
              <input type="submit" value="{{ button_continue }}" class="btn btn-primary" />
            </div>
          </div>
        </form>
        {{ content_bottom }}
      </div>
      {{ column_right }}
    </div>
  </div>
</div>
{{ footer }}